In some respects we are spoilt for choice in Rotorua. Our whenua (land) boasts an abundance of stunning natural thermal resources, and we consider our lakes and forests world-class.
Our hapori (community) is also renowned for its thriving tourism industry that attracts global recognition. Our cultural capital is that our hapū, iwi and marae have stood resolute against the test of population decline, political hegemony and oppressive legislation (since the signing of Te Tiriti o Waitangi in 1840).
Recently our community of Fordlands hit the national headlines. To our communal shame, the Rotorua suburb ‘boasts’ significant deprivation, with the New Zealand Index of Multiple Deprivation (IMD) reporting Fordlands is home to the most socio-economically deprived neighbourhood in Aotearoa/New Zealand.
In contrast, and despite the 2011 Christchurch earthquake and its aftermath, the Christchurch suburb of Merivale was found by IMD to be home to the neighbourhood with the most advantage and therefore least deprivation.
What, if anything, do these findings have to do with health equity, one might ask? Everything, is the only plausible answer!
Inequity in action: Fordlands and Merivale
In this article, I revisit the definition of health equity, then consider the contrasting worlds of living in the Merivale neighbourhood with its abundance of resources and wealthy people and living in Fordlands with its very few resources or wealthy people. I will then loop back and consider Rotorua’s success factors as a community, and how these are embedded within the health system – or not – as the case may be.
Starting with Fordlands, the 2013 census data indicates a population of about 1,700. People in the community are mostly Māori. About 45 per cent have no qualifications, almost the same percentage have a level 1-6 qualification, and the predominant occupation is labourer. The average income is between $10,000 and $20,000 per annum, 60 per cent of families in Fordlands are sole parents, and most live in rented dwellings. The neighbourhood has one block of corner shops including a Four Square supermarket and a liquor store.
There are two general practices (seven doctors) near Fordlands – one is 40 minutes’ walk and the other is almost an hour’s walk. Neither practice is on the bus route. The children’s parks are minimal, and a far cry from other parks in the advantaged areas of Rotorua. Gang presence is not uncommon, requiring parents to consider whether riding a bike in their neighbourhood is safe2.
Merivale’s census data and demographic profile indicates that most of the advantaged suburb’s about 2,706 people are European, 23 per cent have a degree and they earn in excess of $70,000 per annum. A property search of the area comes up with descriptions like ‘architecturally-designed splendour, impeccable landscaping and an array of shopping facilities’.
A quick search for general practices reveals at least five (25 doctors) and most practices can be walked to in roughly five to ten minutes, plus there’s a private hospital to boot. Not only are the people of Merivale spoilt for GP choice, they also reside in a health-enhancing environment.
Whitehead’s widely used definition of health inequity is “health inequalities that are avoidable, unnecessary and unfair are unjust”. Braveman broadens the definition to argue that health equity is the absence of disparities for socially disadvantaged populations that are persistently exposed to systemic discrimination within a society.
A health equity lens would suggest that the Fordlands residents’ disproportionately low share of resources is unfair, avoidable and unjust. In contrast the people of Merivale have financial means, many are university-educated and – adding to their advantage – have greater access to government-funded primary health care and local government amenities. Being healthy it seems is accumulative – it’s a whole lot easier at the top, and when you live in areas of affluence.
Arguably, the system and structures are skewed favourably towards the people who live in Merivale, not Fordlands. This is avoidable, and disrupting the status quo is within the remit of policy decision-makers and nurse leadership. It is remiss to blame individuals, instead we must always apply a critical and health equity lens on the system and the, at times invisible, bias towards privilege.
We should take a lesson from Rotorua’s main industry, tourism, an industry reliant on attracting people to our community and providing services that meet tourists’ wants, needs, cultural worldview, preferences and desires. Tourism makes it their core business to understand these factors and unashamedly moulds itself around its target populations. Simply to do otherwise would bankrupt an entire industry.
The health industry – with DHB budget blowouts and burgeoning demand outstripping supply – is arguably an industry near bankruptcy. Taking a lesson or two from tourism seems both logical and sensible.
Another strength for Rotorua is its marae: focal points for whānau, hapū and iwi and places where Māori take reo, kawa and tikanga for granted. Whakapapa connects individuals, and from this place a sense of belonging is affirmed. Roles and responsibilities are equally valued, which is critical to sustaining livelihoods.
But how are these strengths reflected in the design of systems? And, importantly, are we truly ready to design systems to meet the needs of people most in need and move closer to health equity?
Fordlands neighbourhood statistics in 2013:
- 1,701 residents, mostly Māori.
- 45 per cent have no qualifications.
- Average income of $10-20,000 per annum.
- 60 per cent are single parent families – most live in rented dwellings.
- Seven GPs: 1,700 people = one GP for every 243 people.
Merivale neighbourhood statistics in 2013:
- 2,706 residents, mostly European (89.5 per cent).
- 23 per cent are degree qualified.
- Average income of $70,000 per annum.
- 25 GPs: 2,700 people = one GP for every 108 people.
Sonia Hawkins is a registered nurse, director consultant for Te Pani Limited and a College of Nurses Aotearoa board member.